Provider Demographics
NPI:1790747566
Name:MIKOLIC, JOSEPH F (CRNA)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:F
Last Name:MIKOLIC
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 MACKUBIN ST
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55102-2021
Mailing Address - Country:US
Mailing Address - Phone:651-222-4265
Mailing Address - Fax:
Practice Address - Street 1:75 MACKUBIN ST
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-2021
Practice Address - Country:US
Practice Address - Phone:651-222-4265
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2012-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 133937-2367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN5600 89 800Medicaid
MN5600 89 800Medicaid